Healthcare Provider Details

I. General information

NPI: 1487012480
Provider Name (Legal Business Name): LAKE SPIVEY AMBULATORY SURGERY CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2016
Last Update Date: 02/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7813 SPIVEY STATION BLVD SUITE 100
JONESBORO GA
30236-2900
US

IV. Provider business mailing address

11 UPPER RIVERDALE RD SW
RIVERDALE GA
30274-2615
US

V. Phone/Fax

Practice location:
  • Phone: 770-268-6000
  • Fax:
Mailing address:
  • Phone: 770-991-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number031127
License Number StateGA

VIII. Authorized Official

Name: CHRISTOPHER DOAN
Title or Position: CHIEF COMPLIANCE COUNSEL
Credential:
Phone: 909-235-4307